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      Compensation claims
         Accdts & Untoward incidents
            Compensation for Train accidents or untoward incident
               Annexure
                  Annexure-III


 
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Annexure-III

ANNEXURE- III

                                                                         FORM   II

 Application under Section 16 of the Act in respect of claims for compensation arising out of accident to a train.

                                                PART I

 Title of the case:  Name of the applicant ---------------- Applicant / s

                                                    vs.  

                            U.O.I through G.M. / -------------    Respondent

PART  II

   INDEX

      S. No           Description  of documents attached         Page  No.        

       1.               Railway report, if any.

       2.               G R P S’s report

       3                Railway ticket or authority to travel.

4.Death Certificate

       5               Post-mortem report.

       6               Legal heir certificate

     7.              Medical certificate, in case of injury

                                                                                                                                                                                 Signature of the Applicant

                                                                                                                                                ,Date of filling

       For use in Tribunal’s office                                                                                                                                                 Or  

Date of receipt by postRegistration No.  
Signature for Registrar

PART III

  To                                  

The Railway Claims Tribunal.

I._________, son / daughter / Wife / Widow of  ________________   residing at__________  having been injured in railway accident hereby apply for the grant of compensation for the injury sustained.

I. _________son / daughter / window of ___________ residing at______________________hereby apply as dependent for the grant of compensation on account of the death / injury/ sustained by Shri / Kumar / Shriman/ Shrimati______________ son / daughter / wife / widow of Shri / Shrimati_________ who died / was injured in the railway accident referred to hereunder. 

Necessary particulars in respect of the deceased / injured in the accident are given below:

1.      Name and father’s name of the person injured / dead (husband’s name in the case of married women or widow.):

2.      Full address of the person injured / dead.

3.     Age of the person injured / dead:

4.       Occupation of the person injured / dead:

5.       Name and address of the employed of the deceased, if any:

6.       Brief Particulars of the accident indicating the date and place of accident and the name of the train involved:

7.      Class of travel and ticket / pass number, to the extent known:

8.      Name of injuries sustained along with medical certificate :

9.    Nature and address of the Medical Officer/ Practioner, if any who attended the injured/ dead and period of treatment:

10.     Disability for work, if any caused:

11.     Details of the loss of any luggage on account of the accident:

12.     Has any claims been lodged with any other authority? If so, particulars

thereof___________________________________________________

13.     Name and permanent address of the applicant:__________________

14.    Local address of the applicant, if any ___________________________

15.        Relationship with the deceased / injured:____________________

16.        Amount of compensation claimed:_________________________

 

17.      Where the application is not made within one year of the occurrence of the accident, thegrounds thereof:____

18.  Any other information or documentary evidence that may be necessary or helpful in the disposal of the claim _

19.       Mention the documents, if any , filed along with applicationI, _______________ _______solemnlydeclare that:

a)    the particulars given above are true and correct to the best of any knowledge and

b)   I have not claimed or obtained any compensation in relation to the injury / death ,whichis the subject matter of the application.

                                Signature or the thumb –impression of applicant

Date----------

Place--------

Name of witness and his address in case left thumb Impression is put by the applicant

  VERIFICATION      

I, ___________________(name of the applicant) S/o, D/o, W/o_______________________ _____________________  

Age__________________resident of_______________ Do hereby verify that the contents of paragraphs  to are  true to my personal knowledge and paragraphs _ to _ arebelieved to be true to the best of my knowledge or the legal advice  given to me and that I have not suppressed any materials l fact.

      Signature of the applicant

                         Full address

Date:

  Place: 

 

To

  The Registrar,

Railway Claims Tribunal,

 

 

 

 

 




Source : South Eastern Railway CMS Team Last Reviewed on: 06-08-2013  


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